• By Katherine Hafner and Gary Harki 
  The Virginian-Pilot
• Oct 13, 2018 Updated 2 hrs ago

GOOCHLAND, VA.

Victoria Addison was sifting through boxes of her biological mother’s belongings from prison when she came across the handwritten pleas for help.

“I still can’t keep anything down and my throat is still hurting me,” Jennifer Addison, 44, wrote March 6 on an emergency grievance form inside the Virginia Correctional Center for Women in Goochland. “I need some help please."

Two days later, Jennifer was dead. She had been serving a sentence for credit card fraud in Virginia Beach and was due to be released in about three months.

“She was denied help, begging for it,” Victoria said. “She deserved help. She wasn’t there to die.”

Victoria, 25, had a long and complicated relationship with her biological mother, but when she found the neatly filled-out forms from prison, she was horrified. She’d already suspected there was more to Jennifer’s story than what she’d been told.

“To be honest, it’s because there have been a lot of other stories about inmates just dying in prisons and it made me wonder what happened,” Victoria said.

Jennifer Addison’s death fits into a broad pattern of problems with health care at jails and prisons in Virginia, as well as specific concerns about the handling of grievance forms submitted by inmates in need of medical care.

Her case mirrors that of Henry Stewart, who died in the Hampton Roads Regional Jail in August 2016 after filling out forms begging for help. Stewart, 60, was locked up for violating probation on a shoplifting charge. His requests were denied, according to a man incarcerated there at the time and documentation provided to The Virginian-Pilot by his family.

After Stewart’s death, then-Gov. Terry McAuliffe called for more jail oversight, and state Attorney General Mark Herring requested a Justice Department investigation, which is ongoing.

Another state prison just 35 miles from Goochland, the Fluvanna Correctional Center for Women, has been under a federal court order since 2016 to improve its health care because of deaths like Addison’s. This summer the DOC was dragged back into court by the inmate plaintiffs, who alleged that Fluvanna was still not meeting inmates’ medical needs. A five-day bench trial was held in June. The judge has yet to issue a ruling.

The Pilot contacted the offices of Gov. Ralph Northam, state Secretary of Public Safety and Homeland Security Brian Moran, state Attorney General Herring and the Virginia Department of Corrections seeking comment about what happened to Addison and about the DOC’s ongoing health care problems.

A spokeswoman for Herring’s office referred questions to the Department of Corrections. “Every death is a serious matter and should be treated as such,” she said in an email.

Northam and Moran’s offices did not respond.

“We take our constitutional duty to provide health care to the incarcerated population very seriously,” DOC spokeswoman Lisa Kinney wrote in an email. “Generally speaking, offenders often come to Virginia's prisons having never had much contact with health care providers, and are receiving the first regular, continuous health care of their lives in prison. Offenders tend to be sicker than the general population when they come to us, and sometimes have chronic conditions that haven't been addressed on the outside.”

People who have no political power are easy to ignore, said Deborah Golden, a prisoners' rights attorney at the Human Rights Defense Center.

“It's about deciding that some people's lives aren't worth it,” she said. “It's the system as a whole, but I think that there are specific individuals who could change that.”

The three forms filled out by Jennifer Addison were tucked in among romance novels, drawings and other possessions that Victoria received in the mail after her biological mother’s death.

Had Jennifer not written down her requests for help – and kept a copy of each form – there would likely be no indication of what really happened to her in her final days.

The first form was a request for medical attention on March 4, four days before she died.

“My throat is sora(sic), Im having hot/cold sweats, and throwing up everything I eat or drink. This has been going on since Monday 26, of last month,” she wrote.

On an emergency grievance form two days later, Jennifer again asked for help and described her interaction with prison staff the night before.

“I’ve been sick for almost a week and our night offier(sic) Ms. Seaberry called medical and nurse Smith has seen me and told me that she can’t do anything for me at 10:00 p.m.,” she wrote. “But she will give me cough medinie and Tyleal(sic) and put me in to see Dr. John today, I have told her Ive already put a sick call slip in. I still can’t keep anything down and my throat is still hurting me. I need some help please.”

More than three hours after the form was turned in, a nurse checked two boxes in the staff response portion. The first was next to the sentence “Your grievance does not meet the definition for an emergency.”

The second: “Submit Sick Call Request.”

On the last full day of her life Jennifer filled out a third form – a permission slip to miss a group activity.

“Sore Thorat(sic), Throwing up, hardly able to talk,” she wrote. “I Have put a sick call.”

At around 11:45 that night, prison staff found her unresponsive in her cell.

They tried to resuscitate her, then took her to the West Creek Emergency Center. She was pronounced dead in the emergency room at 1:25 a.m. on March 8, according to the autopsy, which said she had been coughing up blood.

Jennifer had also hurt herself not long before she died, the autopsy revealed. There were several unclosed, healing cuts on her left wrist. Her cause of death is listed as the flu and MRSA – a bacterial infection resistant to many antibiotics, which led to a blood infection.

"She shouldn't have died of that. That's totally treatable. ... That's outrageous," Golden said. "Anyone who wasn't holding food down for six days would have gone to the ER. She needed medical attention."

Dr. Marc Stern, a correctional health consultant and affiliate assistant professor at the University of Washington School of Public Health, said it appears that prison workers should have done more when they saw Jennifer’s grievance form.

“This is an inappropriate response to an emergency grievance request, especially in light that she already put in a sick call,” he said.

But he added that Addison’s medical record – which the DOC denied Victoria’s request to obtain – would be needed to accurately assess whether her life could have been saved.

“Was this a preventable death? It’s hard to tell,” Stern said.

The flu and bacterial complications are treatable, he said. “If you don’t get treatment at all, your chances of surviving are much poorer.”

It’s unclear whether Jennifer received any treatment. Stern added that he doesn’t believe the cuts on her wrist in any way led to her death.

“It typically takes days for a bacterial infection to develop from the flu,” Stern said. “This didn’t happen in an hour.”

Jennifer Addison was bornin Georgia but grew up in Norfolk, drifting in and out of jails and prisons for most of her adult life.

Her mother had a drinking problem and worked as a prostitute. She brought home a parade of men, some of whom abused Jennifer, according to an undated letter Jennifer wrote that her family provided to The Pilot.

“When I told mom she would tell me that it was my fault and then she would take a belt buckle and beat me and as she is beating me she calls me names like slut, and Jezebel and that I was trying to take her man from her,” Jennifer wrote. “But it was nothing like that.”

Soon Jennifer followed in her mother’s footsteps, working as a prostitute and doing drugs, “living from hotel to hotel and going for days not caring about anything.”

She never found a way out of that life.

At 19, she was in jail and pregnant, and sought help from a Bible ministry.

Brenda Dain, a former police officer who has raised more than 28 children over the years as a foster mother, met Jennifer through a friend who told her that the teenager was looking to find her baby a home. Dain, a Chesapeake resident, volunteered to take her.

Victoria, now 25, was born a few weeks after her mother was released from jail. Jennifer, meanwhile, went into rehab but left soon afterward to go back on the streets, a cycle she would never break.

“When I did get out I tried to do better and I did for awhile but I got dored(sic) with that life and went back to do what I knew the only way to live,” she wrote. “And that was prostitute and drugs.”

Dain said she understands and agrees that people who commit crimes should be punished and shouldn’t expect indulgences while they’re locked up.

“I don’t think they should have the luxuries of home,” she said. “But everybody deserves to have medical care.”

Jennifer likely had untreated mental illness, she said, but did not appear to have other chronic medical conditions.

“Jennifer did nothing to get (the) death penalty for,” Dain said. “But she got it.”

The Virginia Correctional Center for Women, where Addison died, houses almost 100 female inmates from Hampton Roads, about a quarter of the women from the region who are in state prison. It sits along the James River in Goochland, 15 minutes off Interstate 64.

Just 35 miles away lies the Fluvanna Correctional Center for Women, once held up as DOC’s model facility.

Constant denials of medication, refusing requests to see a doctor and missed appointments for chronic care helped prompt a 2012 lawsuit against Fluvanna in federal court alleging a “systemic, pervasive and on-going” failure to meet minimum standards of inmate care.

In February 2016, Fluvanna prison officials and inmates finalized a settlement that installed a compliance monitor over the prison, which did not admit wrongdoing. The terms were designed to bring the level of care up to the bare minimum a state must provide for those it imprisons.

But more than two years later, the people who brought the lawsuit say Fluvanna officials have yet to meet that standard. This summer, they brought the DOC back to court, arguing that it has not complied with the settlement agreement.

“The women at the Fluvanna have been punished twice – once for their crimes and a second time by DOC's poor medical care,” Angela Ciolfi, an attorney for the plaintiffs, said at the trial in June, according to transcripts.

A Miami-based contractor, Armor Correctional Health Services, took over at Fluvanna in 2014, two years after the lawsuit was filed against the prison. Its contract was renewed in 2015 for $81.8 million, a bid that attorneys now argue Armor accepted “knowing it could not provide adequate services at that price.”

DOC officials waited for the situation to get better under Armor, with a compliance monitor watching closely. Soon the state started discussing taking over prisoner health care itself.

According to court documents, officials did step in earlier this year, but it’s unclear what role Armor still plays. The company’s contract is up this month, and the DOC did not respond to questions about whether it will be renewed.

”We do not have the resources to adequately address this settlement agreement,” Fluvanna’s then-Warden Jeffrey Dillman said in an internal letter from 2017, according to court documents. “...We are destined to fail.”

In addition to the federal lawsuit, a host of other legal challenges have been filed relating to DOC’s treatment of inmates.

Just last month a Suffolk family sued the department, alleging that Arlene Duke died in 2016 at Fluvanna after officials failed to provide her with sufficient medical care.

Another lawsuit claims that a mentally ill inmate at Red Onion State Prison in Wise County was housed in isolation for more than a decade, an allegation the state denies. Another charges that Virginia’s DOC does not adequately treat inmates – as much as 40 percent of the total state prison population – who have hepatitis C.

The department also came under scrutiny recently for announcing that it was banning women who visit its facilities from wearing tampons in an effort to prevent smuggling of contraband. The ban was put on hold a day later after women’s rights groups and several state delegates decried the policy in formal letters and on social media.

Ciolfi does not believe that any improvements made at Fluvanna in response to the federal lawsuit have carried over to the rest of Virginia’s prison system.

“We get correspondence from prisoners all over the state,” she said. “We hear about many of the same problems. It wouldn't surprise me if they are even worse in some other places. I think the state truly has not grappled with the consequences of locking so many people up for so long and the extraordinary cost – both the human cost and fiscal cost of what that means. I think there is a culture that this is the way that it is.”

At the heart of both the Fluvanna lawsuit and Addison’s death is a grievance system that determines who receives emergency medical care and when.

Once a prisoner asks in writing for help, the form is reviewed by prison staff, who accept or reject the request. Previously at Fluvanna, a prison guard, not a doctor or nurse, frequently made that decision.

“I think the system set in place for people to seek care has all been really designed to discourage people from seeking care and to encourage staff to find the quickest, least expensive way to get rid of the complaints,” Ciolfi told The Pilot. “I think it's designed that way and there’s a culture that supports it.”

DOC officials have resisted changes to the grievance system, she said.

“In order to be considered an emergency – and this is DOC policy – it has to be imminently life-threatening or in danger of loss of limb,” she said. “Basically, if it were a true emergency you probably wouldn't be able to fill out an emergency grievance.”

Still, the grievance policy changed at Fluvanna before the June trial in which inmates sued the DOC for alleged contempt of the consent agreement that had settled their previous lawsuit.

Dr. Robert Greifinger, former chief medical officer for the New York state prison system and an expert witness for the plaintiffs in the lawsuit, testified that the DOC was working hard to fix the problem with grievances at Fluvanna. Now, a registered nurse must look over each form and someone must examine the inmate. An ombudsman also reviews the form.

But it remains unclear whether that system or the old one is being used elsewhere in Virginia – and which was in force when Addison pleaded for help in Goochland. Addison's request did appear to have been rejected by a registered nurse.

DOC officials did not respond to an emailed question about which system is used at Goochland.

Complaints about the old grievance system resurfaced during the trial.

Greifinger testified about a woman with a longstanding blood clotting disorder who could not get her medicine.

“She filed an emergency grievance saying why am I not getting my medicine, and their response was this does not meet the definition of an emergency,” he testified during the trial. “This is another example of the cynicism. … This is a woman who will develop blood clots if she doesn't take that medication. It is a life-threatening emergency not to get that medication.”

The next day, her leg was purple, warm and swollen – symptoms consistent with a blood clot. She was taken to the hospital, put back on her medications and discharged.

Ciolfi questions whether the improved grievance process at Fluvanna is sustainable.

“The legislature hasn’t been asked to increase funding. They’ve been asking the Department of Corrections to bring health care costs down" she said. "They only act when there's outside pressure. When their feet are held to the fire. It's really tragic that it takes that kind of pressure to move the needle on what they are obviously capable of doing. “

During the federal trial, held in the Western District of Virginia in Charlottesville, U.S. District Judge Norman K. Moon, in apparent frustration with the DOC, questioned the department's actions.

“It's sort of like they're – it's complaining,” Moon said of DOC officials, according to court transcripts. “It looks like somebody should have gone to the legislature three or four years ago and asked for the money. … It should be, you would think, just in the ordinary course of, we've got to care for these patients.”